Improving Education: Promoting Practice-Based Prescribing Competencies for New Nurse Practitioners

The release of the Institute of Medicine's publication, To Err is Human: Building a Safer Health System revealed the amount of medical errors and threats to patient safety that occur within the U.S. healthcare system. Since its publication, many initiatives have been created in order to reduce medical errors and promote patient safety. As such, much importance has been placed on the use of competency-based learning in healthcare education and practice because competencies outline the knowledge and skills necessary to deliver safe and ethical care. In the U.S., nurse practitioners' (NP) scope of practice allows the ability to prescribe medications. Prescribing is a complex process that needs to be done safely and competently in order to promote patient safety and optimize healthcare delivery. NPs first obtain their prescribing competency in their formal education. Several studies have shown that new prescribers report having low prescribing confidence and insufficient prescribing competency which may lead to medication errors, malpractice, and patient harm. Healthcare curricula are now moving from the method of "knowledge acquisition" to "knowledge demonstration" by instituting competency-based learning. A systematic literature review of various methods to improve prescribing competency suggests that competency-based learning is the most effective method. The American Association of Colleges of Nursing (AACN) released a white paper in 2015 urging that advanced practice registered nurses' (APRN) education should be competency-based and further mentions that no current nationally accepted method of defining, measuring, and assessing for practice-based prescribing competency exists. Therefore, the purpose of this project was to develop a practice-based prescribing competencies for new NPs. The first objective of this project was to develop and refine current core prescribing competencies for new NPs. The second objective was to create practice-based outcome statements that effectively demonstrate the developed core prescribing competencies for new NPs. The third objective was to create a checklist of observable actions which achieve the developed practice-based outcome statements and competencies in a clinical setting. Finally, the fourth objective was to disseminate project findings at a poster presentation at a local medical/surgical conference. Thirty-one prescribing competencies developed by the Oregon State Board of Nursing (OSBN) for APRN pharmacological management evaluation were placed into a survey and were emailed to NPs practicing in Utah. The survey asked the NPs to rate which prescribing competencies were most important for new NPs. The results of the survey were analyzed and a list of current practice-based prescribing competencies was created. A low survey response rate greatly limited the generalization of this project's findings. A clinical practicum checklist of observable actions was then created which addressed each competency and outcome statement in order to help facilitate the assessment of an NP's demonstration of the practice-based prescribing competencies. Competency-based learning is becoming widely used in healthcare education and promotes patient safety and quality of care. The final product of this project will help improve NP education and practice and thus have a positive impact on patient safety and improvement of quality of care.

Running head: PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS Improving Education: Promoting Practice-Based Prescribing Competencies for New Nurse Practitioners Rogelio (Roy) Lugo, BSN, RN, A/GACNP-DNP Student University of Utah in partial fulfillment of the requirements for the Doctorate of Nursing Practice 1 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 2 Executive Summary The release of the Institute of Medicine's publication, To Err is Human: Building a Safer Health System revealed the amount of medical errors and threats to patient safety that occur within the U.S. healthcare system. Since its publication, many initiatives have been created in order to reduce medical errors and promote patient safety. As such, much importance has been placed on the use of competency-based learning in healthcare education and practice because competencies outline the knowledge and skills necessary to deliver safe and ethical care. In the U.S., nurse practitioners' (NP) scope of practice allows the ability to prescribe medications. Prescribing is a complex process that needs to be done safely and competently in order to promote patient safety and optimize healthcare delivery. NPs first obtain their prescribing competency in their formal education. Several studies have shown that new prescribers report having low prescribing confidence and insufficient prescribing competency which may lead to medication errors, malpractice, and patient harm. Healthcare curricula are now moving from the method of "knowledge acquisition" to "knowledge demonstration" by instituting competency-based learning. A systematic literature review of various methods to improve prescribing competency suggests that competency-based learning is the most effective method. The American Association of Colleges of Nursing (AACN) released a white paper in 2015 urging that advanced practice registered nurses' (APRN) education should be competencybased and further mentions that no current nationally accepted method of defining, measuring, and assessing for practice-based prescribing competency exists. Therefore, the purpose of this project was to develop a practice-based prescribing competencies for new NPs. The first objective of this project was to develop and refine current core prescribing competencies for new NPs. The second objective was to create practice-based outcome statements that effectively demonstrate the developed core prescribing competencies for new NPs. The third objective was to create a checklist of observable actions which achieve the developed practice-based outcome statements and competencies in a clinical setting. Finally, the fourth objective was to disseminate project findings at a poster presentation at a local medical/surgical conference. Thirty-one prescribing competencies developed by the Oregon State Board of Nursing (OSBN) for APRN pharmacological management evaluation were placed into a survey and were emailed to NPs practicing in Utah. The survey asked the NPs to rate which prescribing competencies were most important for new NPs. The results of the survey were analyzed and a list of current practice-based prescribing competencies was created. A low survey response rate greatly limited the generalization of this project's findings. A clinical practicum checklist of observable actions was then created which addressed each competency and outcome statement in order to help facilitate the assessment of an NP's demonstration of the practice-based prescribing competencies. Competency-based learning is becoming widely used in healthcare education and promotes patient safety and quality of care. The final product of this project will help improve NP education and practice and thus have a positive impact on patient safety and improvement of quality of care. This project contained a project committee consisting of Perry Gee RN, PhD who was the project chair, Denise Ward, ACNP-BC, FNP-BC, DNP who was the program track director, and Pam Hardin, RN, PhD who was the assistant dean for masters and doctorate nurse practitioner programs. The content expert of this project was Tracy Klein, PhD, FNP, APRN, FAANP, FRE, FAAN. 3 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS Table of Contents Executive Summary Problem Statement Clinical Significance and Policy Implication Purpose Statement Objectives Literature Search Strategy Literature Review Theoretical Framework Implementation Evaluation Results Recommendations DNP Essentials Conclusion References Appendix A Appendix B Appendix C Appendix D Appendix E Appendix F Appendix G Appendix H Appendix I Appendix J 2 4 4 6 6 6 6 11 12 14 16 18 19 20 22 26 30 44 46 49 52 57 59 67 69 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 4 Improving Education: Promoting Practice-Based Prescribing Competencies for New Nurse Practitioners Problem Statement In the United States, nurse practitioners' (NP) scope of practice allows for the ability to prescribe medications. The act of prescribing is a complex process that needs to be done safely and competently in order to optimize delivery of healthcare and ensure patient safety. NPs begin to obtain their prescribing competency within their formal education and it is further built upon as they progress throughout their career. It is imperative that NPs' formal education and career training properly prepare NPs to have the prescribing competency necessary in order to deliver safe, high quality healthcare. The American Association of Colleges of Nursing (AACN, 2015) recently released a white paper regarding the need to "re-envision" the clinical education of advanced practice registered nurses (APRN) which includes the role of NPs. APRN education throughout the United States has varied assessment and measurement standards and clinical opportunities which thus results in inconsistent educational outcomes. The AACN (2015) discussed the need for APRN clinical education to move from the traditional measures of "…seat time or credit hours as metrics of student achievement to the identification of observable, measurable competencies…" (p. 20). The AACN (2015) goes on further to mention the desire for APRN programs to adopt competency-based education, yet currently, no nationally accepted assessment tool for prescribing competency exists. Therefore, in order to ensure adequate and consistent NP prescribing education and training, practice-based prescribing competencies need to be developed, accepted, and implemented at a national level. Clinical Significance and Policy Implications PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 5 The utilization of competency-based learning for prescribing can affect many stakeholders. New prescribers (e.g. physicians, nurse practitioners, physician assistants) report having low prescribing confidence and insufficient prescribing competency which can lead to poor healthcare delivery and patient harm (Brennan & Mattick, 2012; Velo & Minuz, 2009). Prescribers themselves are held legally accountable for failure to comply with appropriate medication prescribing policies and subsequent patient harm that may arise. Negligent prescribing is one of the top 10 reasons for medical malpractice for physicians and may result in criminal charges and medical board disciplinary action (Wittich, Burkle, & Lanier, 2014). Patients are also affected by inappropriate medication prescribing practices as consequent medication errors may arise. Prescribing errors occur in 26-56% adults, and in 68-75% children and consequences include increased mortality/morbidity, length of stay, readmission, and healthcare costs (Alanazi, Tully, & Lewis, 2016; Wittich et al., 2014). The root cause of medication prescribing errors may be the result of a lack of proper prescriber education. The use of practice-based prescribing competencies in the education and training of new prescribers, may help mitigate these negative outcomes. Specific to the field of advanced practice nursing, the use of competency-based learning for prescribing may help improve advanced practice nursing's professionalism and scope of practice. The AACN (2015) mentions that other healthcare disciplines (e.g. physical therapy and medicine) have begun to use competency-based learning to improve quality and promote safety. The adoption of competency-based learning is essential for advanced practice nursing to promote excellence and professionalism. Furthermore, as NP scope of practice varies from state to state in the U.S., the use of competency-based learning specific to prescribing practices can help facilitate the nationwide acceptance of independent, unrestricted NP prescriptive authority and PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 6 full scope of practice. The implementation of practice-based prescribing competencies within a graduate curriculum may eliminate state-specific prescribing restrictions for new graduate NPs (Klein & Kaplan, 2010). Purpose Statement The purpose of this DNP scholarly project is to develop a method for promoting practicebased prescribing competencies for new NPs. Objectives 1. Develop and refine current core prescribing competencies for new NPs. 2. Develop practice-based outcome statements that effectively demonstrate the developed core prescribing competencies for new NPs. 3. Identify learning strategies which achieve developed practice-based outcome statements and competencies within a clinical setting. 4. Disseminate project findings during the Ogden Surgical-Medical Society (OSMS) Conference. Literature Search Strategy Search terms used: prescribing, competencies, APRN, NP, education, safety, medication. Search databases used: CINHAL, PubMed, Google Scholar. Articles pertaining to other disciplines, such as medicine, were included due to similarities in prescribing practices with NPs. Articles not originally written in English were excluded due to uncertainty of translation. Articles older than 10 years were excluded due to possibility of outdated information. Literature Review Background PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 7 Care provided within the healthcare system should be as safe as possible. The release of the Institute of Medicine's (IOM, 1999), To Err is Human: Building a Safer Health System, revealed that care provided in the American healthcare system was anything but safe in large part due to medical errors. The IOM defines a medical error as, "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim" (1999, p. 1). The consequences of medical errors result in patient harm, increased healthcare costs, and poor faith in the healthcare system (IOM, 1999). Markay and Daniel (2016) mention that medical errors are the third leading cause of death in the United States with an estimated incidence rate of 210,000400,00 deaths a year in hospitalized patients. As such, since the IOM's 1999 report, many initiatives have been created in order to improve quality of healthcare and promote patient safety (Lenburg et al., 2009) including the use of competency-based learning for healthcare providers. Medication Errors Due to the vast expanse of healthcare, many pathways for potential medical errors to occur exist. Approximately 50% of Americans report taking at least one prescription medication (Wittich et al., 2014). The extensive use of medications in the United States creates a large concern for the potential of medical errors, specifically medication errors. Within the inpatient setting, medication error rates have been reported to be about 4.8%-5.3% (Wittich et al., 2014). Medication errors have tremendous consequences such as increased patient length of stay, hospital readmission, patient harm, and emotional distress (Hayes, Jackson, Davidson, & Power, 2015). In 2013, an estimated cost of $19.6 billion was seen from preventable medication errors and its sequelae of hospital admissions, emergency room visits, and outpatient encounters (Dreischulte et al., 2016). Prescribers themselves are also affected by medication errors. As previously mentioned, prescribers may face legal consequences or disciplinary action related to PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 8 medication errors. Imprudent prescribing is one of the top 10 reasons for medical malpractice for physicians (Wittich, Burkle, & Lanier, 2014). In a systematic review by Wallace, Lawry, Smith, and Fahey (2013), it was found that medication errors were the second most comment reason for malpractice and prescribers reported their lack of proper prescribing education in their formal training as a potential cause for error. Prescribing Errors Medication errors can be categorized by which phase of the medication process the error occurs in: prescribing, dispensing, administration, or monitoring (Reckmann, Westbrook, Koh, Lo, & Day, 2009). According to Alanazi, Tully, and Lewis (2016), prescription errors are the most common category of medication error and range from 29% to 56% in adults. Errors that may occur in the prescription phase include but are not limited to missing patient information, illegibility, miscalculation, incorrect use of abbreviations, and missing drug information (Hsu et al., 2015). The use of computerized provider order entry (CPOE) has been shown to reduce the aforementioned prescribing-related errors. Studies have shown that the use of CPOE versus handwritten orders to reduce the overall amount of medication errors, especially in the prescription phase (Hinojosa-Amaya et al., 2016; Hsu et al., 2015; Reckmann et al., 2009). However, the use of CPOE is not without errors of its own. In a systematic review done by Reckmann, Westbrook, Koh, Lo, and Day (2009) which analyzed the impact of CPOE on medication errors, it was found that new errors specific to CPOE occurred such as duplicate orders, failure to discontinue orders, technical errors, missed drug allergies, and bypassing of computerized warnings. Furthermore, despite the reduction of medication errors seen with PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 9 CPOE, the severity of errors that do occur are more serious than errors from handwritten orders (Hinojosa-Amaya et al., 2016; Reckmann et al., 2009). Compliance with appropriate medication prescribing practices are of the utmost importance. Prudent medication prescribing practices may help reduce medication errors because as mentioned before, the majority of medication errors occur during the medication prescribing stage (Reckman et al., 2009). Key elements of medication prescribing include completeness, legibility, purpose, and relevant precautions (Kienle & Uselton, 2008). Despite the implementation of computer provider ordering entry (CPOE) technologies and increases in medication error reporting, medication prescribing errors still persist. According to Nazar et al., "…at an individual level, prescribing errors are attributable to a lack of training in practical prescribing and failure to link theory to practice" (2015, p. 278). Therefore, the need for educational intervention for presciber education is vital. Education and Competency-Based Learning Several interventions have been used to reduce the occurrence of medication errors within the prescribing phase. Despite various methods and results, the most effect method seen to decrease prescribing errors is proper education regarding the essentials of prudent prescription writing (Aronson, 2006; Drieschulte et al., 2016; Hsu et al., 2015). However, education itself is complex and multifaceted and thus requires an evidence-based approach in order to utilize the most effective method. Healthcare is comprised of various disciplines which each take their own unique approach to education and training. A movement of curriculum development from "knowledge acquisition" to "knowledge demonstration" with subsequent need for assessment and measurement has been seen in various healthcare disciplines (Wainright, Klein, & Daly, 2016). PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 10 Psychiatry, medicine, and physical therapy are examples of healthcare disciplines that utilize competency-based learning within their curricula. Competency is "…knowledge, skills, and judgement required to perform safely and ethically in practice…and provides a foundation for which safe, competent, and ethical care can be demonstrated" (Wainright et al., 2016, p. 2). In a systematic review by Kamarudin, Penn, Chaar, and Moles (2013) which looked at various educational methods to improve prescribing competency, a competency-based approached was most effective method of improving prescribing ability. Previously mentioned, was the AACN's (2015) call to action for APRN clinical education to "re-envision" its approach to education. As such, the AACN (2015) urges for APRN colleges to adopt the use of competency-based learning. Unfortunately, as was seen in the medical community, the transition for APRN education to use competency-based learning is slow to progress and will take time to be adopted. New Prescribers According to Dearden, Mellanby, Cameron, and Harden (2015), newly graduated doctors have a high occurrence of prescription errors at a rate of 7.4% to 10.3%. Additionally, Tobaiqy, McLay, and Ross (2006) mention that 30% of post-graduate doctors report not feeling confident in prescribing medications due to their lack of clinical pharmacology and therapeutics training in their medical education. Whereas the medication errors and prescribing competency of new NPs has not been deeply measured, it would be safe to assume new NPs may have similar rates and results to their medically-trained counterparts. To see a reduction of medication errors, specifically during the prescription phase, education should be aimed towards newly graduated prescribers. Seeing as how NP education and training does not have a current method for using competency-based learning, it would be PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 11 prudent to establish methods to promote the use of competency-based learning specific to prescribing practices in the interest of improving new NP prescribing competency and confidence, patient outcomes, and quality of delivered healthcare. Theoretical Framework The healthcare field continuously strives to promote patient safety and deliver a high level of quality healthcare. As such, competency-based learning has increased in emphasis in the healthcare field because of its ability to achieve patient safety and optimize healthcare delivery. However, implementing competency-based learning in practice and/or education is varied throughout and results in inconsistent outcomes. Therefore, the use of a theoretical framework developed for promoting competency-based learning is paramount for guiding this DNP project. The Competency Outcomes Performance Assessment (COPA) model was created as a framework which helps guide the development of competency-based learning in practice (Lenburg, Klein, Abdur-Rahman, Spencer, & Boyer, 2009). When the COPA model is used to guide competency-based learning, it will "…promote competent, effective professional practice and patient safety" (Lenburg et al., 2009, p. 317). The COPA model defines four essential conceptual pillars which promote competency for practice (a) core practice competencies; (b) competency outcomes; (c) interactive, practice-focused learning; (d) competency performance examinations and assessments (Lenburg et al., 2009). The extent of this DNP project will utilize the first three pillars defined by the COPA model. The COPA model asks questions associated with each pillar. The questions associated with the first three pillars that will be used to guide the implementation of this DNP project are (a) what are current, essential competencies required for practice; (b) what are the most effective outcome statements that demonstrate those PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 12 competencies; (c) what are the most effective learning strategies to achieve the outcomes (Lenburg et al., 2009). Implementation After DNP project proposal (see Appendix A) approval, a survey was developed using the web-based software, REDCap (see Appendix B). The developed survey was titled, "APRN Prescribing Competency Survey." The survey contained six demographic questions (age, gender, primary role, level of education, primary population focus, years with prescriptive authority) and the remainder of the survey was developed in a Lickert-type style. The chosen prescribing competencies were acquired from the Oregon State Board of Nursing's (OSBN, 2014) APRN Pharmacological Management Evaluation Form Part B which contained 31 prescribing competencies (see Appendix C). The OSBN's prescribing competencies were chosen because they have been previously validated and were already written for novice NPs. In order to have the study participants evaluate each prescribing competency, a validated tool developed by Wainright, Klein, and Daly (2016) was adapted to fit the scope of this DNP project and thus asked five questions (four rating and one free text) for each prescribing competency. An invitation email to the survey was also composed and included information as to why the participants were being contacted, background for the survey, and the purpose of the survey (see Appendix D). An application for the Institutional Review Board (IRB) at the University of Utah was completed and this study was ultimately deemed exempt (see Appendix E). Inclusion criteria for study participants were APRNs actively licensed in the state of Utah. Exclusion criteria for study participants excluded non-English speaking participants. Participant emails were obtained from the Utah Division of Occupational and Professional Licensing's (DOPL) licensee list of APRNs and APRNs controlled substance actively licensed in the state of Utah. An application PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 13 for the request of licensees' emails was required by DOPL which ultimately was filled out, submitted, and approved by DOPL. The survey was emailed out to participants (n=2079) with emails registered in DOPL via REDCap. The survey was live for a total of 33 days with a reminder survey invitation email sent out on day 15. The intention of objective two was to take the approved competencies from the survey results from objective one and word them in a way that was suggested by the COPA model. According to the COPA model (Lenberg et al., 2009), competency outcomes should be written as end-result practice expectations and should reflect what the learner actually should do in practice. Upon deeper review of the OSBN's APRN Pharmacology Management Evaluation Form Part B (2014), the competencies surveyed in objective one were labeled as "practice behaviors" which were already written in a manner that coincided with the COPA model's recommendations for competency outcomes. The COPA model (Lenberg et al., 2009) does, however, define eight core practice competency areas that must be addressed in clinical learning. The OSBN's (2014) practice behaviors were categorized into seven domains adapted from the American Nurses Association (Klein & Kaplan, 2010). Since the COPA model was the guiding theoretical framework for this DNP project, the surveyed competencies from objective one were categorized into the one of the eight core practice competency categories defined by the COPA model (Lenberg, et al., 2009) which were: assessment and intervention skills, communication, critical thinking skills, human caring/relationship skills, teaching skills, management skills, leadership skills, and knowledge integration skills. Next, the COPA model (Lenberg et al., 2009) explains that once outcome statements are clearly defined and relate to the core competencies, learning strategies must be made to achieve the outcomes and strategies. The most effective learning strategies applicable to this DNP project PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 14 were objective observable actions that could be performed in a clinical setting. For every competency obtained from the survey results from objective one, an associated observable action that could be performed in a clinical setting was identified. Due to time constraints, a survey measuring the feasibility and validity of the identified actions for NP faculty and preceptors was unable to be developed. Finally, due to time constraints, the dissemination of this DNP project's findings was changed from creating an abstract for the AANP to attending and presenting at the Ogden Surgical-Medical Society (OSMS) Conference in Ogden, UT which took place on May 17, 2017. An RSVP to present this DNP project's finding was obtained by a representative of OSMS. A poster of this DNP project's findings was created per the recommendations set forth by OSMS (see Appendix F). Evaluation For objective one, the results of the participants' survey responses were analyzed using a REDCap generated data analysis report document. The REDCap generated data analysis report document was shared with the project chair and content expert and a consensus agreement of developed and refined core prescribing competencies were developed based upon the survey responses. Demographic data was recorded and placed into a table (see Appendix G). Since the survey was written in a Lickert-style and ratings ranged from 1-5, ratings of one and two were considered positive for being essential, novice, easily measurable, and clear/concise, three was considered neutral for all category ratings, and four and five were considered positive for being unnecessary, advanced, not easily measurable, and vague/confusing. Per the consensus agreement from the project chair and content expert of this project, it was decided that competencies that were deemed essential, novice, easily measurable, and clear and concise, PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 15 would be considered as applicable prescribing competencies for this DNP project. The free-text feedback responses were only taken into consideration if a competency was essential, novice, easily measurable, but ranked vague and confusing. For objective two, since the surveyed competencies were already written in a style that coincided with the COPA model's definition for competency outcome statements, the project chair and content expert agreed that there was no need to create new outcome statements. The yielded competencies from the surveyed results were categorized into eight core competency categories per the COPA model (Lenberg et al., 2009), however. The organization of the competencies into the COPA model's categories was shared with the project chair and content expert for their agreement of the placement of the competencies into the selected core categories. Objective three required the development of observable actions that could be done in a clinical setting that would achieve the associated competency and outcome statement. The list of identified actions was shared with the project chair, content expert, and two faculty members at the University of Utah. The feedback from the project committee and faculty members was used to revise the actions and a final list of actions was developed. Finally, for objective four, the developed poster was shared with the project chair and content expert to evaluate the poster's content for OSMS's standards. Feedback was received from the project chair and content expert and revisions were made. Attendance and participation at the OSMS conference was conferred. • Objectives Develop and refine current core prescribing competencies for new NPs. Implementation • Develop a survey using a Likert scale that asks participants to rank the OSBN's ARPN practice behaviors (prescribing competencies) on a • Evaluation Consensus agreement from project chair and content expert of a finalization and validation of core prescribing competencies for new PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS • • • Develop practicebased outcome statements that demonstrate the developed core prescribing competencies for new NPs. • • Identify observable actions which achieve developed practicebased outcome statements and competencies in a clinical setting. • 5. Disseminate project findings to during the Ogden SurgicalMedical Society (OSMS) Conference. • • scale of importance for new NPs. Provide survey to APRNs in Utah via email. Analyze survey responses and develop core prescribing competencies for new NPs based on responses. Write-up practicebased competency outcome statements which adequately demonstrate the developed core prescribing competencies for new NPs in practice. Develop clinical practicum checklist of identified observable actions. Validate checklist by using a Likert scale survey that asks NP preceptors and professors to rank likelihood of using and achieving the identified learning strategies. Create a poster to present at the OSMS conference. 16 NPs based upon the survey results. • Consensus agreement from project chair and content expert on created practice-based competency outcome statement content and verbiage. • Consensus agreement from project chair and content expert on finalization and validation of clinical practicum checklist for new NPs. • Consensus agreement of poster content from project chair and content expert. Results For objective one, a total of 182 survey responses were received thus yielding a survey response rate of 8.8%. The results were analyzed using the methods mentioned in the evaluation PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 17 section of this paper. Out of the 31 original OSBN (2014) prescribing competencies, 28 competencies were deemed essential, novice, easily measurable, and clear and concise (see Appendix H). Limitations of this objective were the low survey response rate and certain demographic data. The survey itself had a total of 161 questions which was viewed as "timeconsuming" by recipients and thus declined to take such a long survey. Not only did the length of the survey contribute to the low response rate, but so did other factors. From the 2,079 email addresses received from DOPL, approximately 200 of those email addresses were incorrect. Other survey recipients had other reasons for declining to participate such as retirement, no long practicing in Utah, or general disinterest. Interestingly, some respondents replied with a request of the survey results final product as a general interest in promoting practice-based prescribing competency for new NPs. Due to time constraints, actions to increase the survey response rate were unable to be taken beyond a one-time survey reminder email sent 15 days after the initial survey invitation. In regards to demographic limitations, the age of the respondents was low for the age range of 20-29 (n=6) compared to the other age ranges (see Appendix G). More females (n=154) responded than males (n=28), however this may be representative of how the nursing profession is mostly female-dominated. Of all APRNs that responded, 167 (91.8%) were NPs. This would make the results of the survey generalizable for the NP role only which was the aim of this project. 127 (70.2%) held a master's degree and 47 (26.0%) held a doctorate of nursing practice (DNP). As such, as the U.S. moves more toward the use of DNP programs, it would be beneficial to have more DNP respondents as to generalize this data to DNP curricula and new DNP NP graduates. Objective two did not result in revision of the "practice behaviors" used by the OSBN (2014). Instead, the 28 competencies that resulted from objective one were categorized into the PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 18 eight core competency categories per the COPA model (Lenberg et al., 2009, see Appendix H). A limitation of this objective may include the subjectivity of the categorization of the competencies into the categories set forth by the COPA model. Objective three resulted in the development of 1-2 actions for each surveyed competency (see Appendix G). These actions may be placed into a checklist and be used in a clinical setting to assist new NPs in achieving the prescribing competencies and outcome statements associated with each action. A limitation of this objective was the lack of proper validation of the identified actions. Due to time constraints, the identified actions were unable to be surveyed for feasibility by a group of NP faculty and preceptors. Objective four resulted in the dissemination of this DNP project's findings. A poster was created and presented at the OSMS conference (see Appendix I). Informal feedback received from conference peers was taken into consideration for the further development of this DNP project. A poster was also created and presented at the University of Utah's College of Nursing DNP final project poster presentation (see Appendix J). Recommendations The identified actions associated with the prescribing competency outcome statements require further validation. An expert panel of clinical preceptors and/or instructors could review the identified actions and offer their professional feedback on the actions' feasibility and reliability. Once the actions are agreed to be feasible and reliable, they should be pilot tested in either an NP student's clinical rotation or new graduate NP's job training as a means to obtain validation that the identified actions yield improvement in the participant's prescribing competency. PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 19 Once the identified actions are able to adequately demonstrate that they achieve their associated competency and outcome, this DNP project's findings could be adopted by a university or healthcare system which would implement the use of practice-based prescribing competencies into their curriculum or employee training. This would require buy-in from a university's education board or a healthcare system's administration. If practice-based prescribing competencies do become implemented in either setting, it would be ideal to measure pre- and post-implementation prescribing competencies to show the impact of the implementation. In a live patient environment, it would be essential to measure changes in medication error rates, patient satisfaction, malpractice events, and patient safety. If the use of these practice-based prescribing competencies shows improvement in medication error rates, patient satisfaction, malpractice, patient safety, and prescriber competency, then state or national level of adoption of this DNP project's findings should occur. DNP Essentials Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking DNP Essential II emphasizes that DNP graduates are able to improve patient care and safety at an organizational/systems level (AACN, 2006). The development of practice-based prescribing competencies, outcome statements, and clinical checklist for new NPs, promotes the prescribing competency of the NP thus resulting in safer patient care. The findings of this DNP project can be adopted by a healthcare organization or system. Once implemented into the healthcare organization or system, NP prescribing competency will be improved which will be to the benefit of all populations served by the NPs. The harmful effects of poor prescribing competency, such as patient harm and increased medical costs will be mitigated as well. PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 20 Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice DNP Essential III mentions that DNP graduates are able to seek out and appraise information and implement findings into practice (AACN, 2006). The process of developing this DNP project included identification of a problem, a literature review, intentions of improving practice, and dissemination of findings. This DNP project has delivered valuable experience of conducting research and contributing to evidence-based practice. Essential VII: Advanced Nursing Practice DNP Essential VII involves the increased specialization of skills a DNP graduate receives upon advancing their education (AACN, 2006). Among these skills includes the ability to prescribe. This DNP project aims to improve the prescribing competency of NPs thus improving the advanced nursing practice for those APRNs who can prescribe. Improved prescribing competency will promote excellence within the field of nursing. Conclusion This DNP project aimed to facilitate a process for new NPs to adopt the use of practicebased prescribing competencies in NP education and training. Due to the low survey response rate and need for further clinical action validation, this DNP's project requires continued data collection and its findings are not yet generalizable to new NPs. However, this DNP project's purpose could serve as a catalyst for the promotion of using practice-based prescribing competencies NP education and training. As with most instances that require a change in approach to education or training, adoption of competency-based learning may be slow and require much refining. Prescribing is just one area of NP practice that could benefit from the use of competencybased learning in education and training. A concerted effort must be made to improve all aspects PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 21 of healthcare practice. Healthcare is a dynamic field that continuously strives for improvement, as such, various healthcare disciplines are beginning to implement competency-based learning into their practice due to its positive impact in healthcare delivery and patient outcomes. PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 22 References Alanazi, M. A., Tully, M. P., & Lewis, P. J. (2016). A system review of the prevalence and incidence of prescribing errors with high-risk medicines in hospitals. Journal of Clinical Pharmacy and Therapeutics, 41, 239-245. doi: 10.1111/jcpt.12389 American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from http://www.aacn.nche.edu/dnp/Essentials.pdf American Association of Colleges of Nursing (AACN). (2015). Re-envisioning the clinical education of advanced practice registered nurses. Retrieved from http://www.aacn.nche.edu/aacn-publications/white-papers/APRN-Clinical-Education.pdf Aronson, J. K. (2006). Editors' view: A prescription for better prescribing. British Journal of Clinical Pharmacology, 61(5), 487-489. doi: 10.1111/j.1365-2125.2006.02649.x Brennan, N. & Mattick, K. (2012). A systematic review of educational interventions to change behavior of prescribers in hospital settings, with emphasis on new prescribers. British Journal of Clinical Pharmacology, 75(2), 359-372. doi: 10.1111/j.13652125.2012.044397.x Dearden, E., Mellanby, E., Cameron, H., & Harden, J. (2015). Which non-technical skills do junior doctors require to prescribe safely? A systematic review. The Journal of Clinical Pharmacology, 80(6), 1303-1314. doi: 10.1111/bcp.12735 Dreischulte, T., Donnan, P., Grant, A., Hapca, A., McCowan, C., & Guthrie, B. (2016). Safer prescribing-A trial of education, informatics, and financial incentives. The New England Journal of Medicine, 374(11), 1053-1064. Doi: 10.1056/NEJMsa1508955 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 23 Hayes, C., Jackson, D., Davidson, P. M., & Power, T. (2015). Medication errors in hospitals: A literature review of disruptions to nursing practice during medication administration. Journal of Clinical Nursing, 24, 3063-3076. doi: 10.1111/jocn.12944 Hinojosa-Amaya, J. M., Rodriguez-Garcia, F. G., Yeverino-Castro, S. G., Sanchez-Cardenas, M., Villarreal-Alarcon, M. A., & Galarza-Delgado, D. A. (2016). Medication errors: Electronic vs. paper-based prescribing. Experience at a tertiary care university hospital. Journal of Evaluation in Clinical Practice, 1-4. doi: 10.1111/jep.12535 Hsu, C., Chou, C., Chen, T., Ho, C., Lee, C., & Chou, Y. (2015). Physicians failed to write flawless prescriptions when computerized physician order entry system crashed. Journal of Clinical Therapeutics, 37(5), 1076-1080. doi: 10.1016/j.clinthera.2015.03.003 Institute of Medicine. (1999). To err is human: Building a safer health system. Retrieved from http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/1999/To-Err-isHuman/To%20Err%20is%20Human%201999%20%20report%20brief.pdf Kamarudin, G., Penm, J., Chaar, B., & Moles, R. (2013). Educational interventions to improve prescribing competency: A systematic review. BMJ Open, 3, 1-18. doi: 10.1136/bmjopen-2013-003291 Klein, T. & Kaplan, L. (2010). Prescribing competencies for advanced practice registered nurses. The Journal for Nurse Practitioners, 6(2), 115-122. Doi: 10.1016/j.nurpra.2009.09.016 Kienle, P., & Uselton, J. P. (2008). Maintaining compliance with joint commission medication standards. Retrieved from http://psqh.com/julaug08/medication.html Lenburg, C. B., Klein, C., Abdur-Rahman, V., Spencer, T., & Boyer, S. (2009). The copa model: A comprehensive framework designed to promote quality care and competence for patient safety. Nursing Education Perspectives, 30(5), 312-317. PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 24 Nazar, H., Nazar, M., Rothwell, C., Portlock, J., Chaytor, A., & Husband, A. (2015). Teaching safe prescribing to medical students: Perspectives in the UK. Advances in Medical Education and Practice, 6, 279-295. doi: 10.2147/AMEP.S56179 Markay, M. & Daniel, M. (2016). Medical error-the third leading cause of death in the US. The BMJ, 353, 1-5. doi: 10.1136/bmj.i2139 Oregon State Board of Nursing. (OSBN, 2014). APRN pharmacological management evaluation form part b [PDF]. Retrieved from https://www.oregon.gov/OSBN/pdfs/form/APRNPharmaMgmtEvalFormPartB.pdf Reckman, M. H., Westbrook, J. I., Koh, Y., Lo, C., & Day, R. O. (2009). Does computer provider order entry reduce prescribing errors for hospital inpatients? A systematic review. Journal of the American Medical Informatics Association, 16(5), 613-623. doi: 10.1197/jamia.M3050 Tobaiqy, M., McLay, J., & Ross, S. (2007). Foundation year 1 doctors and clinical pharmacology and therapeutics teaching. A retrospective view in light of experience. British Journal of Clinical Pharmacology, 63(3), 363-372. doi: 10.1111/j.1365-2125 Velo, G. P. & Minuz, P. (2009). Medication errors: prescribing faults and prescription errors. British Journal of Clinical Pharmacology, 67(6), 624-628. doi: 10.1111/l.13652125.2009.03425.x Wainright, A., Klein, T., & Daly, C. (2016). Competency development to support safe nurse practitioner prescribing of controlled drugs and substances in british columbia. Policy, Politics, & Nursing Practice, 0(0), 1-11. doi:10.1177/1527154416665099 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 25 Wallace, E., Lawry, J., Smith, S. M., & Fahey, T. (2013). The epidemiology of practice claims in primary care: A systematic review. BMJ Open, 3(1-8). doi: 10.1136/bmjopen-2013002929 Wittich, C. M., Burkle, C. M., & Lanier, W. L. (2014). Medication errors: An overview for clinicians. Mayo Clinic Proceedings, 89(8), 1116-1125. doi: 10.1016.j.mayocp.2014.05.007 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS Appendix A DNP Project Proposal PowerPoint 26 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 27 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 28 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 29 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS Appendix B APRN Prescribing Competency Survey 30 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 31 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 32 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 33 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 34 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 35 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 36 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 37 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 38 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 39 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 40 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 41 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 42 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 43 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS Appendix C OSBN APRN Pharmacological Management Evaluation Form Part B 44 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 45 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS Appendix D Survey Invitation Email 46 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 47 Hello, My name is Roy Lugo and I am a DNP student at the University of Utah. I am contacting you because I would like your voluntary professional opinion regarding the development of practicebased prescribing competencies for new nurse practitioners (defined as nurse practitioners with less than one year experience) and nurse practitioner students. You are being invited to take part in this research survey because you are currently licensed as an APRN in Utah who prescribes medications. This research survey will be asking you six demographic questions and will also ask you to rank 31 prescribing competencies on a scale of importance for new nurse practitioners and nurse practitioner students. The chosen prescribing competencies are from the Oregon State Board of Nursing's (OSBN, 2014) APRN Pharmacological Evaluation of Practice Behaviors and the Likert-type scale is adapted from Wainright et al., (2016). You can take the research survey at any time and you have the option to save your progress and return at a later time. The research survey should take about an hour to complete. Participation in this research survey is voluntary and implies consent. Your identity will remain anonymous and your answers/information provided will remain confidential. Your answers/information will be analyzed along with your peers (other practicing APRNs in Utah) and the development of practice-based prescribing competences for new nurse practitioners and nurse practitioner students will be produced. The final product of this project will be created by April 2017. If you would like to see the final product you may ask the investigator, Roy Lugo, to send you a copy at the completion of this study. THE LINK TO THE SURVEY: https://redcap01.brisc.utah.edu/ccts/redcap/surveys/?s=DWTDJN7F4H More information: Title of Study: Improving Education: Promoting Practice-Based Prescribing Competency for New Nurse Practitioners Background: Healthcare education and practice preparation are moving towards the use of practice-based competencies within their curricula. The use of practice-based competencies promotes competent and effective professional practice and promotes patient safety, thus improving the quality of care delivered and promote patient safety. According to the American Association of Colleges of Nursing (AACN, 2015), currently, no nationally accepted method of defining, measuring, and assessing practice-based competencies specific to prescribing exist for nurse practitioners. New nurse practitioners have been reported to have low prescribing confidence and insufficient prescribing competence which may lead to prescribing errors, threats to patient safety, poorly delivered healthcare, and malpractice. Therefore, the purpose of this study is to develop a method to promote practice-based prescribing competencies for new nurse practitioners and nurse practitioner students. PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 48 If you have any questions, concerns, or complaints, you may contact: Roy Lugo (principle investigator) [e-mail] Perry Gee (project chair) [e-mail] Thank you. Roy Lugo, RN, BSN, AGACNP Student (University of Utah) References American Association of Colleges of Nursing (AACN). (2015). Re-envisioning the clinical education of advanced practice registered nurses. Retrieved from http://www.aacn.nche.edu/aacn-publications/white-papers/APRN-Clinical-Education.pdf Oregon State Board of Nursing. (OSBN, 2014). APRN pharmacological management evaluation form part b [PDF]. Retrieved from https://www.oregon.gov/OSBN/pdfs/form/APRNPharmaMgmtEvalFormPartB.pdf Wainright, A., Klein, T., & Daly, C. (2016). Competency development to support safe nurse practitioner prescribing of controlled drugs and substances in British Columbia. Policy, Politics, & Nursing Practice, 0(0), 1-11. doi:10.1177/1527154416665099 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS Appendix E IRB Exemption Documentation 49 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 50 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 51 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS Appendix F OSMS Poster Brochure 52 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 53 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 54 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 55 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 56 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS Appendix G Demographic Data Table 57 58 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS DEMOGRAPHIC AGE 20-29 30-39 40-49 50-59 60-69 GENDER MALE FEMALE PRIMARY ROLE NP CRNA CNM CNS/CNL EDUCATOR RESEARCHER LEVEL OF EDUCATION MASTER'S POST-GRADUATE CERTIFICATE DOCTORATE PHD OTHER PRIMARY POPULATION FOCUS ADULT/GERONTOLOGY FAMILY PEDIATRICS WOMEN'S HEALTH NEONATAL MENTAL HEALTH/PSYCHIATRIC YEARS WITH PRESCRIPTIVE AUTHORITY <1 1-5 6-10 11-15 16-20 20+ N(=182) % 6 48 42 51 35 3.3% 26.4% 23.1% 28% 19.2% 28 154 15.4% 84.6% 167 0 2 3 7 3 91.8% 0% 1.1% 1.6% 3.8% 1.6% 127 11 47 9 1 70.2% 6.1% 26.0% 5.0% 0.6% 57 73 18 9 4 18 31.8% 40.8% 10.1% 5.0% 2.2% 10.1% 24 53 28 31 23 23 13.2% 29.1% 15.4% 17.0% 12.6% 12.6% PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS Appendix H Survey Results Competencies, Outcome Statements, and Actions 59 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 60 Core Competency: Assessment and Intervention Skills Outcome Statement: Assesses client health care risks including environmental, cultural, educational and other risks which may impact therapeutic decision-making • Action: Perform an assessment which identifies client specific health care risks (environmental, cultural, education, etc.) which may impact therapeutic decision-making. Outcome Statement: Assesses the client's therapeutic self-management including any use of integrative medicine. • Action: Perform an assessment of client's therapeutic self-management which includes the use of integrative medicine (e.g. lifestyle, biochemical, biomechanical, and bioenergetic therapies). Outcome Statement: Monitors the safety and efficacy of drug therapy treatment plan • Action: Identify a patient currently taking a medication that requires increased monitoring. Develop and continuously maintain a plan that monitors the patient's safety while on the drug therapy and monitors the efficacy of the therapy. Outcome Statement: Incorporates and orders periodic lab testing or monitoring into treatment plan • Action: Identify 5 commonly used medications in your clinical setting. Identify which labs or other forms of monitoring are required while taking the identified medications. Order relevant labs/monitoring associated with the identified medications and perform subsequent action required based on lab/monitoring results. PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 61 Outcome Statement: Modifies treatment plan as appropriate based upon therapeutic outcome and response • Action: Identify a client who requires modification in their treatment plan due to therapeutic outcome or response. Develop a change in the treatment plan that demonstrates appropriate action based upon their therapeutic outcome/response. Core Competency: Communication Skills Outcome Statement: Accurately performs a comprehensive, problem-focused, or interval medical history including current and previous diseases or conditions • Action: Perform a comprehensive, problem-focused, or interval medical history which includes current and previous diseases or conditions Outcome Statement: Collects and documents data appropriate to individual client's health needs • Action: Identify and collect information that is unique to a patient in your clinical setting and document the information in the patient's health record. Outcome Statement: Documents and validates data from patient interview and comprehensive evaluation of available clinical information regarding client's physical and overall health status • Action: Perform a patient interview and correlate/validate the information obtained from the patient with family, other medical records, and other healthcare providers. Document data in the patient's medical record. Outcome Statement: Establishes and documents medical diagnosis and appropriate differential diagnosis to serve as basis for pharmacological management PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS • 62 Action: Choose a patient in your clinical setting. For each of their medications, correlate with a patient's diagnosis or differential diagnosis. Outcome Statement: Writes clear, legible, and complete prescriptions and/or orders which comply with state and federal regulations • Action: Demonstrate clear and accurate prescription transmission using written, telephonic, fax or electronic methods consistent with state and federal regulations Outcome Statement: Gives clear written and/or verbal instructions to client regarding obtaining, using, and monitoring their medications • Action: Provide a patient in your clinical setting with clear written and/or verbal instructions to client regarding obtaining, using, and monitoring their medications Outcome Statement: Accurately and promptly records clinical notes which reflect client assessment and pharmacological management plan • Action: Ensure clinical notes are accurately and promptly documented in the patient's clinical record. Outcome Statement: Protects sensitive client communications while enhancing therapeutic information sharing • Action: Identify methods in your clinical setting that are available to protect sensitive client communication and determine instances in which they could be used to enhance therapeutic information sharing. PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 63 Outcome Statement: Adapts communication style to meet the needs of the client regarding pharmacologic treatment and recommendations • Action: Demonstrate an adaptation of communication style to meet the needs of the client regarding pharmacologic treatment and recommendations. Core Competency: Human Caring/Relationship Skills Outcome Statement: Identifies and validates client-specific needs while incorporating informed consent from client or health care representative regarding treatment planning • Action: Obtain an informed consent from a patient or health care representative and identify how the informed consent is tailored to specific client needs. Outcome Statement: Prioritizes and develops treatment plan in accordance with mutually agreed upon client/provider goals • Action: Develop treatment plan using mutually agreed upon client/provider goals. Outcome Statement: Provides ethical care for clients including but not limited to incorporating principles of confidentiality, patient self-determination, and issues related to use of information technology • Action: Demonstrate provision of ethical care for a patient which may include but not be limited to incorporating principles of confidentiality, patient self-determination, and issues related to use of information technology Core Competency: Critical Thinking Skills PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 64 Outcome Statement: Interprets client information including laboratory and diagnostic testing and identifies client-specific factors which determine pharmacologic management planning • Action: Choose a patient in your clinical setting. Identify and state how laboratory and/or diagnostic test results for that patient which determine pharmacologic management planning. Outcome Statement: Determines appropriate drug therapy including dose, dosage form, route and frequency of administration • Action: Identify a patient in your clinical setting who requires a change (new, discontinued, or modified drug) in their drug therapy. Provide rationale for change in drug therapy. Outcome Statement: Considers no treatment, non-drug and drug treatment and refers as indicated • Action: Choose a patient in your clinical setting and identify and explore their pharmacologic, non-pharmacologic, and no treatment options and anticipated subsequent referrals. Outcome Statement: Demonstrates competency in drug dosage calculation • Action: Identify a commonly used drug dosage calculation in your clinical setting. Perform drug dosage calculation and verify calculation method/answer with pharmacist. Outcome Statement: Prescribes based on knowledge of pharmacological and physiological principles PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS • 65 Action: Choose a patient in your clinical setting. Using pharmacological and physiological principles, justify the patient's medication treatment plan. Core Competency: Management Skills Outcome Statement: Demonstrates effective working relationship with other members of healthcare team including collaboration, consultation, and referral resources • Action: Identify another member of the healthcare team and how you have effectively worked with them in a collaboration, consultation, or referral manner. Core Competency: Leadership Skills Outcome Statement: Evaluates own practice for continuous improvement opportunities • Action: Identify area(s) of weakness and develop learning plan to improve practice. • Action: Analyze any prescribing errors and develop plan to avoid error in the future. Outcome Statement: Prescribes in accordance with current professional codes of practice and standards • Action: Describe and demonstrate prescribing policies specific to institutional setting. • Action: Describe and demonstrate prescribing policies specific to the state of practice. Outcome Statement: Understands professional commitment to client welfare by providing safe, effective, and appropriate care specific to the Nurse Practitioner or Clinical Nurse Specialist role and scope of practice • Action: Demonstrate a professional commitment to client welfare by providing safe, PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 66 effective, and appropriate care specific to the Nurse Practitioner or Clinical Nurse Specialist role and scope of practice. Core Competency: Teaching Skills Outcome Statement: Provides client specific education regarding use of medication and anticipated effects including cautions • Action: Teach a patient regarding the intended and unintended effects of their medications. Core Competency: Knowledge Integration Skills Outcome Statement: Uses appropriate references and consultation to implement drug regimens (may include collaboration as appropriate) • Action: Collaborate with another healthcare discipline/specialty (e.g. pharmacy, cardiology, neurology) in the development of a patient's medication treatment plan. • Action: Use an electronic evidence-based drug reference tool to help develop a patient's medication treatment plan. PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS Appendix I OSMS Conference Poster 67 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 68 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS Appendix J DNP Final Poster Presentation 69 PRACTICE-BASED PRESCRIBING COMPETENCIES FOR NEW NPS 70